Technology Enhanced Learning Task Force
Final Report
January 30, 2005
Stuart M. Speedie, PhD
Chair
Summary Review of
the Literature
Recommendation:
Learning Spaces (Rank 1)
Recommendation:
Multi-Site Access (Rank 2)
Recommendation:
Simulations (Rank 2)
Recommendation:
Blended Courses ( Rank 2)
Recommendation:
Ad Hoc Communications (Rank 3)
Recommendation: Electronic Medical Records ( Rank 3)
Recommendation:
Computer-based Testing (Rank 3)
Recommendation:
Performance Tracking ( Rank 3)
Recommendation:
Parity ( Rank 4)
Recommendation:
eLearning Preparation ( Rank 4)
Recommendation:
eLearning Resource (Rank 4)
Appendix A: TEL Task Force White Paper
Appendix C: TEL Best Practices at the University of Minnesota
Medical School
Appendix D: Technology Enhanced Learning Methods
In October 2004 Dean Powell directed Senior
Associate Dean Kathleen Watson and Stuart Speedie, Director of Education
Informatics, to convene a task force to consider the utility and costs of
additional investments in technology enhanced learning (TEL) for undergraduate,
graduate and continuing medical education.
The motivation for this work arose from several sources. The
The task
force received the following charge from Dean Powell with respect to their
considerations of technology enhanced learning:
The group was to make recommendations for use of information technology
that would:
Below are the recommendations of the task
force that address items 1,2, 3 of the report.
The report also addresses cost issues within each of the recommendation
discussions. A matrix summarizing the TEL
findings from the literature is contained in Appendix B. A
list of TEL best practices at the
The following recommendations are put forth by the TEL task force in response to the charge to the group. Each row provides label and a one sentence summary of the entire recommendation. And the ranked order of importance in meeting that charge. Multiple recommendations may be listed at the same rank indicating that the task force considered them to be of equal importance.
|
Rank |
Label |
Recommendation Summary |
|
1 |
Learning Spaces |
Create/adopt a common, standard, secure, permanently available student-centered on-line learning space |
|
2 |
Multi-site Access |
Provide multi-site, multi-media access to clinical education activities such as seminars, Grand Rounds, Morning Reports, and clerkship didactic presentations that are accessible from anywhere and at any time with a network connection. |
|
2 |
Simulations |
Increase the use of technology-based simulations and simulators for teaching and evaluating procedural skills. |
|
2 |
Blended Courses |
Work to evolve both basic science and clinical courses with significant lecture content to a more blended approach consisting of a mixture of face-to-face group meetings combined with self-study modules, case-based learning, narrated slide presentations and other on-line activities that the student can complete on their own schedule. |
|
3 |
Ad Hoc Communications |
Develop/adopt means for faculty and students to communicate easily and frequently on an ad hoc basis with each other regardless of site to facilitate advising and student group communications. |
|
3 |
Electronic Health Record |
Introduce the electronic medical record as a teaching tool from the very beginning of the curriculum and work to assure that students have appropriate access to electronic records during their clerkships. |
|
3 |
Computer-based Testing |
Adopt and implement computer-based testing capabilities. |
|
3 |
Performance Tracking |
Develop/adopt a unified, standard student performance tracking system that incorporates all forms of evaluation including classroom tests, faculty evaluations and procedural skills and competencies checklists. |
|
4 |
Parity |
Create parity in learning opportunities for medical students regardless of their personal financial ability to afford the equipment to take advantage of e-learning technologies. |
|
4 |
eLearning Preparation |
Prepare trainees for life-long e-learning by defining competencies in and teaching students e-learning methods. |
|
4 |
eLearning Resources |
Serve as an e-learning resource for
teaching faculty (e.g. RPAP
preceptors, residents, attendings), practicing physicians and health care
systems in |
The estimated costs of implementing these
recommendations fall into two categories and do not take into account existing
Information technology is playing an increasing
prominent role in higher education. Even
when administrative uses such as on-line course registration are excluded, the
uses of computer-based applications for teaching and learning are disseminating
with considerable speed throughout our college and university systems. This approach, now becoming known as
technology enhanced learning or TEL has become a priority initiative at the
At the same time students have come to realize
and are now demanding information technology tools to assist them in their
studies. Surveys of incoming medical
students reveal that essentially 100% either have a computer or have ready
access to one. By the time students
enter their clinical years approximately 80% have purchased a personal digital
assistant. Laptop computers are
appearing in classrooms and students are increasingly dependent on the
electronic resources made available by the
In July of 2000, the
In October 2004 Dean Powell directed Senior
Associate Dean Kathleen Watson and Director of Education Informatics Stuart
Speedie to convene a task force for the purpose of considering the utility and
costs of additional investments in technology enhanced learning for medical
education and extending those investments to the graduate and continuing
medical education. The motivation for
this work arose out of the
The Task force was charged
with making recommendations regarding technology enhanced learning that would:
The following representatives from the
|
Bryan Armitage |
Student, Twin Cities Campus |
|
Bradley Benson, MD |
Faculty, Medicine (pediatrics) |
|
Adam Boettcher |
Student, Twin Cities Campus |
|
Joe Clinton, MD |
Chair, Dept. of Emergency Medicine |
|
Krista Gallagher |
Medical Education Webmaster |
|
Glenn Giesler, PhD |
Faculty, Neuroscience |
|
Gwen Halaas, MD |
RPAP Director, Family Medicine and Community
Health |
|
Richard Hoffman, PhD |
Associate Dean, |
|
Andrew Calvin |
Student, Twin Cities Campus |
|
Linda Perkowski, PhD |
Associate Dean, Twin Cities Campus |
|
Edward Ratner, MD |
Faculty, Dept. of Medicine |
|
Kenneth Roberts, PhD |
Faculty, Dept. of Urologic Surgery |
|
Tom Ronay |
Student, Twin Cities Campus |
|
Janet Shanedling |
Director of Educational Development, |
|
Theodore Thompson, MD |
Director of Clinical Education |
|
Paul Tuite, MD |
Faculty, Neurology |
|
Jennifer Welsh, MD |
Faculty, Family Medicine and Community Health |
|
Eric Celeste |
[insert title], University Libraries |
|
Linda Jorn |
Director, University of |
|
Ramsey Peterson |
Student, |
|
Mark Summers |
TEL Specialist, |
The Table 1 below documents the deliberative process that the task force undertook in order to arrive at its recommendations. Prior to the first meeting of the task force, Stuart Speedie developed a White Paper on technology enhanced learning to inform the members of the current state of TEL in the medical school, describe the current findings from the literature concerning TEL, and to lay the groundwork for the deliberations of the group (See Appendix A). Early in the process the group decided that it could most effectively accomplish its task if it focused the majority of its efforts on the first three charges. Subgroups and/or the task force leadership responded to the balance of the items. In the initial discussion it was recognized that technology enhanced learning is a group of enabling technologies rather than a defining strategy, i.e. TEL is not an educational end in itself. Accordingly the group decided that the best approach their assignment required an examination of and recommendations concerning educational strategies that could be facilitated by technology and that would contribute to a better educational environment for both students and faculty. The table below details the activities of the task force.
|
Date |
Activity |
|
October 14, 2004 |
Organizational Meeting |
|
November 13, 2004 |
Workshop on TEL Outside Speaker/TEL Expert Development of Initial Recommendations |
|
December 2, 2004 |
Review and discussion of initial recommendations |
|
December 3-12, 2004 |
Electronic rating of draft recommendations with respect to overall educational importance. |
|
December 14, 2004 |
Review and discussion of revised recommendations. |
|
December 15-January 12, 2004 |
Electronic rating of draft recommendations with respect to their importance to meeting the charge of the task force. |
|
January 13, 2005 |
Final review and approval of the Recommendations. |
|
January 29, 2005 |
review and approval of Final Report |
|
February 1, 2005 |
Deliver final report to the Dean |
Table
1. Task Force Calendar of Activities.
Stuart Speedie and Edward Ratner undertook a review of the literature in technology enhanced learning (also known as computer-based learning, computer assisted teaching, distance education, among many such terms). This review covered both the medical education literature and the general higher education literature from 1970 to present. The complete review is located in Appendix B. Here we summarize the findings:
It is
important to note that there have been relatively few high quality studies of
the impact of TEL strategies on students and faculty members. One of the principal recommendations of every
review article that has been published is that well designed and controlled
studies need to be conducted to further delineate the impact of such strategies
on student learning. At best the
literature does tell us that TEL strategies can be used to effectively teach
students. The decision to employ a
particular TEL approach must therefore rely upon informed judgments of the
value of such approaches that may be outside the current scope and findings of
the educational literature.
In this section we present the recommendations of the task force in the priority order identified by the group. These recommendations are presented individually and are accompanied by explanatory text that provides the rationale and expected benefits, technologies and infrastructure that will required, and the estimated investment and operating resources that would be required. Investments are defined as the costs of the initial implementation of the recommendation. Continuing expenses are those annual personnel and operating costs necessary to maintain the operation of the implemented recommendation.
|
Create/adopt common, standard, secure, permanently
available student-centered on-line learning spaces that will:
|
Medical students need tools and technologies
that help them to learn more effectively and efficiently. Today the learning tools of most students
consist of a backpack stuffed with textbooks and class handouts with scribbled
marginal notes. These are often
supplemented with paper handouts from the Knowledge Coop or the Note Coop and
printouts of the instructors PowerPoint slides.
Class handouts may point them to certain references in the Bio-Medical
Library. They can review and obtain
additional copies of class materials on the Meded website and can listen to
lectures again at Lectures on Line. In
some courses and clerkships they can go to the course website to find
instructional materials and learning modules that cover the course
concepts. The materials that students
find from course to course and clerkship to clerkship vary greatly in terms of
what is available, where it can be found, and how it is connected to other
parts of the curriculum. Online
materials that are available to students during a course or clerkship may or
may not be available to them after it is finished. While we espouse evidence-based medicine, we
provide few tools to aggregate and organize findings from the literature that
are the basis of this approach. Finally
while excellent materials are being developed and supplied to students on both
the
With the ever expanding body of knowledge in
medicine it is no longer possible for every student or practicing physician to
hold the entire relevant corpus of medicine in their head. The dependence on reference materials,
literature searches and practice guidelines is growing and will continue to
grow for the foreseeable future. Most if
not all of these sources now exist in electronic form and are being designed so
that they can be accessible in a variety of modes from the desktop to the point
of care. Drug references are available
on the Bio-Medical library’s website from any network connected desktop or
laptop and similar versions are widely available for the personal digital
assistant (PDA). Many of the major
references such as Harrison’s,
It is important to note that the Bio-Medical Library may not be able to provide all of the reference materials needs by students. While it does provide access to many electronic resources including full-text journals, there are a number of important and useful references for the PDA that the library does not currently license. Examples of these are the very references mentioned above.
We also need to acknowledge the reality that often students learn a concept or skill the first time it must be used to take care of a patient, not the first time it is taught. Thus for better learning it is wise to facilitate “just in time” learning by providing the ability for students to easily locate and review the knowledge and skills necessary to take care of that patient. They need to be able to do this in a timely manner by being able to locate the relevant information as quickly as possible. Even if the necessary information is available electronically, an organizing structure that the student understands and can readily use is necessary to promote timely access.
To address these issues the task force
recommends that the
To make the learning space a truly powerful and useful tool for students, it must provide easy access to all of the materials that the students need including course objectives; instructional modules for such things as H&P exams, basic science reviews and other materials that may be of assistance in learning. This implies that there needs to be a well-organized repository of these materials analogous to the structure of a library to which the student has complete and continuing access. Since health care is an interprofessional activity and there may well be materials developed in other disciplines that are useful for medical students such a repository should strive to include them where appropriate. Furthermore students need access to these materials is a variety of situations. They need to access them at home from their desktop computer while studying for an exam the next day. They need to access them from their laptop in class as part of a group discussion or problem solving exercise. They need to access them on the wards from the computer at the nursing station or patient bedside. And they may need access from their PDA in the exam room as they are conducting an examination. This implies that the repository of information has to be able to provide its information to students using multiple platforms.
A significant component of this recommendation
is that such a repository be equally accessible and useful on both the
Finally we propose an organizing mechanism for the repository that focuses on the common set of competencies adopted by the faculty that are reflected in the curricular structure and implemented in the courses and clerkships of the curriculum. The basis for this organization already exists in the Curriculum Database and should be expanded and modified to provide an organizing framework for the proposed repository by adding a structure of competencies and objectives.
In many respects the individual components and basic
infrastructure that can be used to build these learning spaces are already in
place. The Medical Education websites at
the
The challenge of implementing this recommendation is to assemble these building blocks into a unified and simple-to-use, integrated system that students can readily make use of for the purpose of learning. All of the components described above were built for different purposes and in many respects do not work well together. Significant effort will be required to create an easy-to-use, integrated system that can bring together all of these diverse components and make that system available for student use whenever they need it and wherever they are located.
The success of this recommendation is critically
dependent on the assistance and cooperation of the Biomedical Library. The systems that they provide for accessing
the literature are especially important to medical education. Their experience of licensing electronic
resources is invaluable and will be of great assistance as we move to expand
the range of resources available to our students. The library can provide the administrative
infrastructure to administer these licensing programs and the
We will also need to work with the University groups that support and administer the WebCT Vista course management system so that is adapted to support this recommendation. Specifically it is necessary for students to maintain permanent access to certain elements of their courses during their entire student career as well as their career as a practicing physician. This requires at a minimum that the student remain “enrolled” in a WebCT course for the four years of undergraduate education and consequently that multiple editions of each course be maintained.
Finally an exceedingly important component of
this infrastructure is the collection of learning modules that constitute the
recommended repository. It should be
recognized that there are a number of these modules already available, some of
which have been created by our own faculty in
While elements of the infrastructure are largely in place, this recommendation will require both a significant startup investment as well as financial resources for continuing support. In particular, the idea of a Learning Space is a cutting edge concept that does not currently exist as commercially available software and so will require investment in software development rather than a direct purchase.
Investment:
The resources required to implement this recommendation fall into three categories: software development required for the learning space concept, module development to create the necessary additions to the repository materials in order to make it a complete and useful resource and purchase of existing commercially available modules where needed. It is estimated that development of the learning space software will require 2 FTE years of software developers at $160,000. This amount would likely be spread over a three year time span. The investment in module development will depend on the number that need to be developed. Current estimates indicate that the development of a single instructional module costs about $7,000. If it is assumed that from 10 to 40 modules would be needed, this would cost from $70,000 to $280,000 including instructional developer time and production costs. This amount would likely be spread over a two year time span. In addition we estimate that it would be necessary to purchase up to $50,000 in additional modules. Thus the total investment amount ranges from $230,000 to $490,000.
Continuing
Expenses:
Continuing expenses will consist of licensing fees for some modules and personnel for ongoing maintenance and continuing development of the system.
Operating Costs: We would anticipate
that licensing fees would range from $0 - $150,000 based primarily on the
number of different references that would be included.
Personnel: It is estimated that this will require a
0.4 FTE systems developer to maintain and improve the system and its
components.
|
Provide multi-site, multi-media access to clinical education activities such as seminars, Grand Rounds, Morning Reports, and clerkship didactic presentations that are accessible from anywhere with a network connection. Record these sessions for later review and for those who need greater flexibility. |
Medical students (undergraduates and residents) are
located on the
The solution proposed is to institute a system
where these sessions are made available to geographically separated sites either
via high quality, interactive videoconferencing or via internet-based webcasting. For example, a Grand Rounds session typically
consists of a PowerPoint presentation on a given topic accompanied by a
discussion among the participants. Using
a combination of the internet to share the PowerPoint slides and interactive
videoconferencing, participants at other than the originating site can fully
participate in the presentation and discussions. Similarly but less expensively, Breeze
technology can be used distribute the slides and audio from the presentation to
any other site connected to the internet and would allow participants to submit
written comments and questions for the presenter. The Breeze approach is significantly less
expensive and could reach a wider audience due to the lower costs of
participation. Employing this technology
would facilitate recording and would make possible the storage and retrieval of
such sessions for later viewing. This
would be similar to what the
The task force believes that implementation of this recommendation would lead to a wider availability of educational activities and could lead to a greater comparability of educational experiences across the spectrum of education due to the ability to share the same educational activity among different geographic locations. In addition, recording of these sessions would provide increased flexibility for students, residents and other physicians who could shift viewing these sessions to times that fit within their own schedules.
Implementation of this recommendation would
require a combination of technologies and high bandwidth internet accessibility
in meeting rooms where these sessions take place. Fortunately
on the
One potentially difficult technical problem that
must be faced is the problem of network firewalls that exist at other
hospitals. Such firewalls often block
videoconferencing and it will be necessary to negotiate separately with each
institution to allow such videoconferencing.
Fortunately there is already a precedent at the
The deficiency in using the Breeze Live method
of recording presentations is that the recorded session cannot be downloaded to
a CD for later viewing as is done now in the Lectures on Line project for Years
1 and 2. If the Breeze server cannot be adapted the
Investment:
To implement this recommendation a range of
investments should be considered based upon the quality desired. For the smallest investment the
Continuing
Expenses:
Annual Operating: This amount ranges from $300 per year for equipment replacement at the low end to $14,000 for Polycom maintenance contracts and $3,000 for equipment replacement for other classroom setups at the high end.
Personnel: Either of the solutions requires 1.5 FTE
Breeze Live, web conferencing and videoconferencing specialists supplemented by
AHC personnel. This assumes that the
utilization of the technology will be on the order of 2-5 sessions per day and
that some assistance will be required for setup and recording of each
session. There is also the need for
someone to manage the
|
Increase the use of technology-based simulations and simulators for teaching and evaluating procedural skills. |
Simulations provide the opportunity for students to practice and learn clinical (both cognitive and procedural) skills without risk to actual patients and in situations that can reduce the cost of instruction. They provide the advantage of practice by being able to repeat the scenario under identical conditions until the skill has been learned to the required level of competence. Simulations also provide the ability to practice in contexts that would occur only very rarely in normal medical care but in which the necessary skills are critical to the survival of the patient. Simulations are of proven value in a number of fields such as airline pilot training and nuclear power plant operation and numerous studies in medicine have demonstrated their utility in learning complex endoscopic and surgical skills.
There are at least two types of simulations. One is strictly software-based and uses interactive screen presentations controlled by the keyboard, mouse or some other mechanical device to teach the skill. These simulations typically have a large cognitive component and may focus more on diagnostic and therapeutic decision making. They typically do not have a physical skill component. The second type is the physical simulation where there is some hardware component that provides a visual and tactile simulation of the patient. These can range from a simple venipuncture simulator that mimics the tactile feedback of inserting a needle into the patient’s vein to full body, computer-controlled simulators with eye blinks, respiration, heartbeat, an airway, etc. that can be used to teach a variety of procedural skills.
This recommendation focuses on the increased use of physical simulators to teach procedural skills to medical students and residents with the possibility of evolving their use into continuing medical education offerings. It recognizes that simulations play a dual role in education in that they can be used either to teach skills or for evaluating the skill level of students. Both uses are equally important. The educational component is useful as an instructional tool that can expose the students to a wider variety of situations. The evaluation aspect is useful in creating and administering standardized scenarios to determine the student’s level of competence in a skill.
The benefits to be derived from these simulations are numerous. There can be more standardized training in procedural skills without risk to patient. The availability of simulators can provide more opportunities for skills training since the student would no longer be dependent on the appearance of a patient in the hospital or clinic with a particular problem in order to practice the skills. There is also the ability to assess student skill levels in a wider variety of standardize situations at reduce costs both in dollars and time. And finally they provide the ability to repeat those assessments across students and across time under the same conditions.
While the
In the case of software-based simulations, the
necessary computer technology is already available though there may be some
need to purchase special items of equipment to use the simulations such as
“joysticks” and 3D goggles. For physical simulations the equipment required will
be the physical simulators themselves. The infrastructure required is the space
necessary to house them and their accompanying support personnel. Fortunately the AHC has developed the IERC
which can provide the necessary space for such simulators and so the principal
resource issue for the
Estimates of the amount required for equipment are dependent on the number of students that require training and the types of simulations desired. For software simulations, the investment required is only the purchase price of the software. For skills expected of all undergraduate medical students, multiple units of simulations will be required. For advance training of residents in specialized skills, one or at most two simulators should be adequate.
Investment:
The prices of simulations vary widely from a few hundred dollars for simple software-based simulations to more than $250,000 for complex, full body simulators. In addition communications with colleagues at other Medical Schools indicate that $500,000 in renovations to existing facilities to house one or more full body simulators in not unreasonable. Fully equipping a simulation laboratory could easily approach $1 million.
Continuing
Costs:
Annual Operating: Operating costs for simulations are dependent on the consumable supplies required. This ranges from essentially $0 for software-based simulations to $80,000 in consumable supplies for full-body simulators.
Personnel:
Physical simulators require attention of and management by dedicated
personnel for anything beyond the simplest levels. While the existing IERC personnel would undoubtedly
handle low level simulations, any full body simulator will require a dedicated,
medically trained coordinator and technician support to fully utilize since a
major activity is developing and executing detailed scenarios using the
simulators. Unfortunately these
simulators do not come with an extensive library of scenarios and they must be
developed locally. Thus implementation
of advanced simulations would require a 1.0 FTE simulation coordinator and a 1.0
FTE simulation technician for an estimated annual total of $170,000.
|
Work to evolve courses with significant lecture content to a more blended approach where in-class time can be reduced and remaining time used more for teaching applications and higher level thinking skills. A blended approach consists of a mixture of face-to-face group meetings combined with self-study modules, case-based learning, narrated slide presentations and other on-line activities that the student can complete on their own schedule. |
In undergraduate medical education, a significant amount of time in both basic science and clinical coursework is devoted to lectures. It should be recognized that lectures are an important and effective instructional tool that do provide the opportunity for an instructor to interact with a large number of students in a short period of time. They can and do provide organization structures for students and are an important motivational tool. Students do learn effectively from lectures and there is no doubt that in medical school they attain the required levels of knowledge in the subjects taught in this mode. Yet because a lecture must take place at a particular place and time, they do reduce the flexibility for individual students by enforcing a single pace on the learning process. In addition while they can provide important conceptual integration and knowledge application opportunities, a significant component of most lectures is information transmission. Evidence from the medical education and higher education literatures tends to support the position that independent learning strategies that do not require a group meeting in a given place at a given time are equally effective in terms of student learning.
Accordingly the task force recommends an approach that blends the best features of both the lecture (face-to-face interactions with the instructor, modeling, and interactive knowledge application) and independent learning approaches in order to promote greater time flexibility for students and faculty. The group believes that greater use of independent learning accommodates students who have different styles of learning and allows students to proceed through the curriculum at a pace that best suites their own needs and abilities. They also maintain that there will be a benefit to faculty after the initial additional time investment in the development of independent learning modules. That benefit will be that less time will be spent in lecture and that time so spent can be devoted to higher level educational activities.
To achieve this blended approach to instruction
will require the availability of a variety of independent learning modules that
cover the full range of topics in the curriculum. Fortunately this has been an area of active
development in medical education and there are numerous products on the market
that address topics from anatomy to urology.
At the same time the University is providing the tools such as Breeze
Presenter to easily convert the information transmission components of lecture
courses to online, independent study modules in the form of narrated PowerPoint
presentations. Live group presentations
can be captured with Breeze Live and preserved for future years. The Twin Cities campus has developed tools
such as the Minnesota Virtual Clinic that are designed to be used for
independent learning. The
Implementing this recommendation requires a
network and server to distribute the independent learning modules to
students. This already is available
through University provided services including the University Gigabit network, WebCT’s
The primary resource needed to implement this
recommendation is the support of technical and instructional personnel to
assist in the development of new modules that are not available otherwise. The University provides numerous resources such
as the
Investment:
It is estimated that approximately $35,000 will need to be spent to buy existing modules that can be used in the classes. For module development, the extent of personnel required is a function of the number of self-instructional modules that would need to be developed internally. The undergraduate medical curriculum currently consists of over 1000 hours of unique lectures per year counting all first and second year courses and clerkship didactic sessions. There are different scenarios that can be pursued. One would be to replace 25% of these lectures with independent learning modules totaling 250 hours. Assuming that about ½ of these would be available commercially the scenario would require the development of 125 hours of instruction. Assuming that a single TEL designer could work with individual faculty members to develop 50 modules per year means that with 1.0 FTE instructional/TEL designers the task could be completed in 2.5 years for a total cost of $175,000. If the percentage replacement was increased to 50%, the task would require 2.0 FTEs for the same period of time and would cost $$350,000.
Continuing
Costs:
Annual Operating: It is likely that some commercially available material will require licensing rather than purchase. Depending upon the materials required we estimate an annual cost of up to $75,000.
Personnel:
There will be the need for 1.0 FTE in technical support to assist
with testing and making the modules available to the students. This is an annual total cost of $55,000.
|
Develop/adopt means for faculty and students to communicate easily and frequently on an ad hoc basis with each other regardless of site to facilitate advising and student group communications. |
Students and residents are located at numerous
sites throughout the state. In addition
to Year 1 and 2 students on both the
The Task Force suggests a combination of
technologies depending on the location of the communicating parties to
implement this recommendation. When the
parties have access to existing videoconferencing facilities in the
Since implementing this recommendation would make use of campus networks, existing videoconferencing facilities and internet attached computers, the principal equipment purchase would be webcams and software to be used for PC-based video.
Investment:
Implementing this recommendation does provide
some choices. To provide a high quality
PC-based solution would require commercial videoconferencing software such as
the Polycom PVX at $120 per station and a webcam at $60 for a total of $180 per
station. A PC solution with minimally acceptable
quality could use Microsoft’s Instant Messenger (free) and a Webcam at $60 for
a total of $60 per station. To equip 10
student advisors, 35 RPAP student sites, and 30 residency sites is $13,500 for
the high quality solution and $4,500 for the minimally acceptable solution.
Continuing
Costs:
Annual Operating: approximately $0
Personnel:
Either approach would require a
0.20 FTE technical support person to assist users in setting up the
software and in resolving technical issues as they arise after the original
dissemination of equipment and software.
|
Introduce the electronic medical record as a teaching tool from the very beginning of the curriculum and work to assure that students have appropriate access to electronic records during their clerkships. |
Electronic medical record (EMR) systems also known as automated medical record (AMR) systems or clinic information systems (CIS) are quickly replacing the paper medical record in patient care. Today our students must make use of these systems in their clerkship and residency programs. They have become the fundamental tool for storing, retrieving and reviewing patient information. The federal government and business groups through a number of initiatives are encouraging and/or requiring EMRs for both hospitals and clinic-based medical practices.
The task force takes the position that just as students benefit from early exposure to patients during Years 1 and 2 of the curriculum, they would also benefit from early exposure to the information systems that, if not now, will soon be integral to the care of those patients. Early exposure would insure that students are trained in the use of and familiar with medical record systems by the time they start seeing patients during their clerkship years. Implementing this recommendation would have the additional benefit of helping to provide a context for the consideration of basic science concepts in the form of simulated patients as is now done with the Minnesota Virtual Clinic. Finally such an EMR could provide a realistic organizing framework for the numerous cases that are used to illustrate clinical concepts during Year 2 and the clinical years of the curricula. This could well be accomplished by an expansion and adaptation of the already developed Minnesota Virtual Clinic. Alternative approaches might be to work with the VA to install a version of their public domain EMR or negotiate with one of the Hospital Information System vendors such as Cerner or Epic for access to a version of their system.
The task force also took the position that just as it is important to have early training in EMRs, the ability to access and use the systems in the various clerkship sites is critical to learning during the clerkship years. Yet there are numerous reports of students having difficulty obtaining authorization to access these EMRs or even experiencing outright denial of access. Therefore to insure a better educational experience during clerkships it is necessary to make arrangements so that these students have the necessary access to the electronic medical records at each clerkship site. It is recognized that the implementation of this portion of the recommendation has more to do with negotiating policies for access at each clerkship site than it does with resource expenditures.
All the necessary equipment and infrastructure
are already in place to implement this recommendation.
The following estimate is based on using either the Minnesota Virtual Clinic (MVC) or a commercial system provided free by the vendor as a means of implementing this recommendation. Addition staff time will be required to work with the clerkship sites to insure appropriate access for students.
Investment:
approximately $0
Continuing
costs:
Annual Operating: These costs are based on the need to support an existing server for the Virtual Clinic for an annual cost $3,000.
Personnel: Implementation of the recommendation will
require a 0.5 FTE technical support person for technical development and
maintenance tasks. It will also explicitly require the involvement of a 0.20
FTE faculty member for oversight of the expanded MVC or the commercial system.
|
Adopt and implement computer-based testing capabilities. |
Computer-based testing (CBT) uses information technology to present test questions to students, collect their answers and assign grades to those tests in an automated fashion. It requires that each student have access to a computer under controlled conditions, usually connected to a network. Test questions reside on and are administered by a server connected to the network. In order to take such a test, the student identifies himself or herself to the server and then is presented questions. The approach works best for automated grading with objective types of questions where the student can select from among a number of distinct alternatives. This includes single and multiple answer multiple choice questions as well as matching questions. Short and long answer text questions can be used but they must be assigned a grade manually. When automated grading is used, the ability to provide the student with results immediately upon completion of the test is available and grades can be automatically entered into a grade book for the instructor. CBT has increased flexibility over paper-based testing in the type of questions that can be used. It allows the easy incorporation of color images and illustrations as well as annotations for those images. It provides the capability of using video and audio clips as part of the question. It provided the ability to present questions in a random order to each student and can enforce time limits on examinations. If desired, tests can be made available to students over a period of time for completion within a given time limit. Finally it allows the possibility of systematically drawing questions from a test question bank so that each student can receive a different set of questions. CBT provides a highly flexible question asking format that can be quite secure and it provides essentially immediate results to students and instructors. Repeated use of CBT within a given course or clerkship facilitates the construction of a bank of questions concerning that can simplify the work in test makers in future years.
There are two primary issues that arise in the use of computer-based testing: security and costs of implementation. Security is an issue from two points of view. First, in high stakes testing, it is necessary to positively identify the person taking the test which some maintain is more difficult to do in computer-based testing. The second aspect of security is a concern about the student’s ability to either access material on the internet while taking a test or to pre-install information on their own computer that would allow them an unfair advantage. Both of these concerns can be addressed by using controlled testing environments such as a computer lab or supplying computers to the students specifically for the test.
It is important to note that the
The task force recommends that the undergraduate
medical education program on the Twin Cities campus adopt computer-based
testing as a means of testing for all courses during the first two years in
parallel to the
A major cost issue involves the cost of
equipment to administer computer-based tests.
One approach has been to emulate as closely as possible the traditional
classroom exam where all students are in the same room and take the exam at the
same time. This requires that every
student have access to a computer at the same time which can be quite costly in
terms of equipment. The
The equipment and infrastructure already exist
to implement this recommendation as it is formulated by the task force. The University’s WebCT Vista course
management system has the capability of conducting secure testing of the type
described above. The Student Computer
Lab can provide the access to the necessary computers to administer these
tests. There in this initial step, there
need be no additional investment in equipment or infrastructure beyond that
used to support the lab currently.
Investment:
Approximately $0.
Continuing
Costs:
Annual Operating: Using the computer lab for high stakes testing requires that all of the equipment remains operational and up-to-date. In order to assure this, it will be necessary to replace all of the computers every three years and to keep a replacement supply available at all times. The cost of doing this is estimated to be $25,000 every 3 yrs for the Twin Cities campus.
Personnel:
Personnel will be required to assist the faculty in the development
of the computer-based exams during the initial phases of the project. This will require a 0.5 FTE evaluation
specialist who will be able to work with individual faculty members to develop
suitably sophisticated test questions that take advantage of the full
capabilities of computer-based testing.
It will also require 0.25 FTE for technical support of test
administration. This is an annual total
of $48,750.
|
Develop/adopt a unified, standard student performance tracking system that incorporates all forms of evaluation including classroom tests, faculty evaluations and procedural skills and competencies checklists and incorporates the technologies currently in use. |
The evaluation of student performance takes numerous forms over the course of a physician’s education. In undergraduate medical education there are classroom tests, faculty evaluations of clerkship performance, certification of skills and competencies, as well as recommendations for residencies. In residencies these take the form of periodic evaluations of performance, procedural documentation, presentations, recommendations, etc. This information now resides in a variety of systems from paper-based grade books, Excel spreadsheets, Vista exam results, paper files, E*Value reports and files and the Registrar’s Peoplesoft system. To aggregate all of this information for a given student is a challenging and time consuming task that discourages attempts to judge that student’s overall competence. The current systems do not incorporate mechanisms for judging and certifying the competencies required of graduating medical students or residents. Yet it is one of the primary responsibilities of the medical school to judge and certify the competence of its graduates.
To address this problem and to lay the groundwork for a more competency-based approach to medical education the task force is recommending the creation of a unified, standard performance tracking system that will be shared by the Twin Cities and Duluth campuses and that aggregates all of the evaluation information for each student and makes it available in a readily useable form while remaining in compliance with FERPA regulations. This would have the additional advantage of providing a means of tracking student performance in order to identify those in need of additional assistance to successfully complete their education and should result in reduced staff time devoted that these activities.
In order to assure security from intrusion and
to protect the records from loss a separate server will be required. The balance of the infrastructure (the
network) is already in place.
Investment:
A server for this purpose can be obtained for a cost of $3,000. The cost for software development will require 2.0 FTE developers for 0.5 years for a total of $90,000.
Continuing
Costs:
Annual Operating: The server will require $3,000 for server support and maintenance from the AHC’s AIS group.
Personnel: A 0.2 FTE information technology professional will be required for
system maintenance and support for a total annual cost of $27,500.
|
Create parity in learning opportunities for medical students regardless of their personal financial ability to afford the equipment necessary to take advantage of e-learning technologies. |
For medical students to take advantage of the web-based or e-learning activities either required or made available by the implementation of the recommendations of this report they must have personal access to standard software, standard computer configurations, broadband internet, and devices such as PDAs. Ideally these devices should provide the same level of functionality and access for all medical students. Yet the current situation falls short of this ideal in that students possess and use a variety of equipment and software that is quite variable in its utility. Too often those differences are dictated by financial concerns and an inability to purchase the necessary computer hardware and software. While medical students all have access to the facilities of the Medical School Student Computer lab, this parity of access does not extend into the classroom, clinical site or home. Students must supply their own laptop to use in class and their own PDAs for clinical rotations.
The thrust of this recommendation is that all medical students should have equal access to the hardware and software necessary for their education. Inequality can arise from a number of sources but one certainly is the lack of a common configuration of hardware and software that is identical for each student. This is an ideal situation where there is both physical and functional equality since everyone has exactly the same hardware and software. One alternative is to approach this from a functionality perspective by working to insure that all students have access to the same functionality even though they may use different hardware to achieve this functionality. At present the school does require that students have access to a computer when they matriculate but makes no further requirements. This works reasonably well for educational activities that require only a web-browser and as long as high-speed access is not necessary. Students can meet this requirement either by having any of a variety of different computers at home connected by slow dialup or by making use of the computers in the student lab. This approach also works reasonable well for supplemental learning materials. But this level of requirement does not facilitate student use of information technology in classroom or in clinical settings since access in these settings requires portable devices such as laptops or PDAs. In order to take greater advantage of the educational uses of information technology it will be necessary to expand the functional requirements of the hardware and software that students must have. For example if we decide that students should have readily available access to drug information during their clerkship rotations, then they will need to have a PDA that is capable of running the microMedix software that is available from the Bio-Medical Library. Similarly if classroom or group discussion activities require that students be able to conduct ad hoc literature searches, then they will need to have wireless laptops or PDAs to accomplish this.
To address this perceived problem the task force
recommends an effort to provide parity by insuring that all students have
access to the same hardware and software at all of the locations where learning
takes place. The basic functions needed
by every student are the ability to access all of the online educational
materials provided by the
To completely implement this recommendation each
student should have a portable computer with broadband wired and wireless
internet capabilities, equipped with basic productivity software (e.g.
Microsoft Office and a web browser and the necessary add-ins such as Flash and
Java Runtime), and a personal digital assistant capable of containing the
reference resources needed for clerkship and residency. While the University
provides much of the technology infrastructure to support this through its
Gigabit network and wireless accessibility, it will be necessary to extend this
broadband access to the student’s home in order to fully realize this
recommendation.
Assuring equality of access as recommended here
does require a significant investment of resources to acquire the necessary
hardware, software and network access for each student. The question is “Who will assume the
burden?” There are a range of solutions
that can address the problem. At one
extreme the
Investment:
In terms of investment we will consider the two
extreme scenarios described above. The minimal cost to the school would be
the Student Responsibility Scenario where students would be required to buy
certain equipment and subscribe to a broadband service. In this approach, the school would still need
to invest in loaner laptops ($30,000) and PDAs ($5,000) to provide backup for
students when they experience equipment problems. In the School Responsibility Scenario, the
Continuing Costs:
Annual Operating: We estimate that in the Student Responsibility Scenario, there would be an annual cost of $33,000 for replacement parts, supplies and software. In the School Responsibility Scenario, there would be the same need for replacement parts, etc. ($33,000). In addition there would be annual subscriptions to broadband services that would total $422,400 for 880 students, and the cost of equipment for each incoming class which would be approximately $420,000 per year.
Personnel: The Student Responsibility Scenario would require 2.0 FTE technical support specialists to assist students with set up of their machines and troubleshooting technical difficulties. The total annual cost would be $110,000. The School Responsibility Scenario would require a 1.0 FTE administrator to oversee the equipment acquisition and distribution process, a 0.25 FTE secretarial support for the administrator and 2.0 FTE technical support specialists to assist students with set up of their machines and troubleshooting technical difficulties. This would amount to a total annual cost of $220,000.
While it might be possible to replace the technical support specialists with outside contract services but the cost is likely to be about the same. Similarly it would also possible to outsource the entire process for these scenarios but again it not reasonable to expect significant annual cost savings.
|
Prepare trainees for life-long e-learning by defining competencies in and teaching students e-learning methods. |
Medical students are a product of their educational background. To be admitted to medical school they have demonstrated that they have acquired highly successful strategies for learning in the current context of higher education. That context relies heavily on the lecture format and our students are very good at learning in traditionally structured educational situations. If the medical school decides to implement any of these recommendations that increase the use of approaches that make greater use of technology-based instructional strategies, there will likely be resistance from students and they may well have more difficulty learning and attaining the required competencies. In a TEL environment students need to be skilled using and learning from asynchronous teaching modules; intelligently and effectively communicating with email, bulletin boards and online discussion groups, instant messaging, teleconferencing, and videoconferencing; effectively and efficiently using a variety of internet search engines; developing online presentations; and evaluating the quality of information on websites. These are learned skills which we cannot now assume our students have when they enter medical school.
The task force recommends that the medical school identify and adopt a specific set of elearning competencies that address the skills and knowledge that medical students need to make effective use of the new information technology-based approaches to teaching and learning. Furthermore, the medical school should include as part of its undergraduate medical curriculum the educational experiences that address these competencies. A cost effective approach to implementing this recommendation would be to develop a set of online instructional and evaluation modules that would teach these competencies to medical students.
Implementation of this recommendation would
require no additional equipment or infrastructure beyond what is currently
available to students.
The required resources to implement this recommendation if it were accomplished as a series of educational modules would be the costs associated with development of the modules.
Investment:
We estimate that six modules need to be developed at a cost of $7,000 per module for a total of $42,000.
Continuing
Costs:
Annual Operating: Approximately $0
Personnel:
To support this program a 0.10
FTE instructor would be required to manage the use of the modules and to interact
with the students as they complete the modules and demonstrate their competence
for a total annual cost of $20,000.
|
Serve as an e-learning resource for teaching
faculty (e.g. RPAP preceptors,
residents, attendings), practicing physicians and health care systems in |
The
Implementation of this recommendation would
require no additional equipment or infrastructure beyond what is currently
available to students. However it might require negotiations with the
University to allow access the resources on University and
These estimates are based on the strategy of repurposing existing resources for the uses described above. As such the only additional resources required would be those associated with any modifications required to make them available to outside professionals or groups.
Investment:
Approximately $0
Continuing
Costs:
Annual Operating: Approximately $0
Personnel:
It is estimated that a 0.5
FTE coordinator and instructional designer would be required to oversee the use
of these materials by the groups described in the recommendation.
The task force puts forward these recommendations with the confidence that their implementation will address the Dean’s charge to the group and will create a better educational environment for medical students, residents, the faculty and the physician community. They are based on the group’s understanding of the literature with respect to technology enhanced learning and the perceived needs of our educational programs.
The group realizes that there is a significant range of cost estimates given choices to be made in the implementation of the various recommendations. In the Table 2 below we attempt to summarize those cost estimates on a per enrolled medical student basis (excluding residents) in terms of high and low cost options and in terms of possible subsets of recommendations that might be selected.
|
|
Cost Category |
|||
|
Investment – 3 years |
Continuing |
|||
|
Estimates |
Low |
High |
Low |
High |
|
Recommendations |
|
|
|
|
|
All |
$490 |
$2676 |
$658 |
$1713 |
|
Ranks 1 – 3 |
$402 |
$2094 |
$433 |
$887 |
|
Ranks 1 – 2 |
$308 |
$2000 |
$170 |
$710 |
|
|
|
|
|
|
|
Learning Space (1) |
$261 |
$557 |
$36 |
$207 |
|
Multi-site Access (2) |
$1 |
$88 |
$144 |
$144 |
|
Simulations (2) |
$1 |
$1136 |
$0 |
$284 |
|
Blended Courses (2) |
$239 |
$402 |
$63 |
$148 |
|
Ad Hoc Communications (2) |
$5 |
$15 |
$13 |
$13 |
|
Electronic Medical Record (3) |
$0 |
$0 |
$76 |
$76 |
|
Computer-based Testing (3) |
$0 |
$0 |
$67 |
$67 |
|
Performance Tracking (3) |
$94 |
$94 |
$35 |
$35 |
|
Parity (4) |
$40 |
$534 |
$163 |
$764 |
|
eLearning Preparation (4) |
$48 |
$48 |
$23 |
$23 |
|
eLearning Resources (4) |
$0 |
$0 |
$40 |
$40 |
Table
2. Cost per Enrolled Medical Student of
Investments and Continuing Costs for Each Recommendation and Certain Combinations. ()’s indicate Ranking
Technology Enhanced Learning
in Medical Education at the
University of
A White Paper
October 12, 2004
Stuart M. Speedie, Ph.D.
Edward Ratner, M.D.
Introduction
The rapid developments in computer and information technologies and tele-communications in the last decade have the potential to profoundly affect Medical Education. These new information technologies provide a set of attractive attributes that can significantly affect many different aspects of the educational environment. Some of these characteristics are:
·
Connectivity
- The Internet provides an unprecedented ability to access resources and
websites throughout the world. The
resources of the National Library of Medicine are now just as accessible as
those in the Bio-Medical Library and the reference books on the office book
shelf. The barriers of access to
information due to geographic distance are rapidly disappearing when such
resources are available on the Internet.
As a result there is an unprecedented breadth of information available
at any internet-connected computer located anywhere in the world. We are also quickly moving toward the ideal of
ubiquitous accessibility with the proliferation of network connections and
wireless access points. Now in major
cities one literally can use the internet wherever one happens to be located –
the street corner, the local coffee shop, a hotel room, or office. With the advent of digital satellite network
any place on earth that has a source of electric power can link to the Internet
as was illustrated by a group of climbers who conducted internet-based telemedicine
consultations and physiologic monitoring while ascending
· Speed – We now have the ability to move information across the internet at speeds that open new communications vistas. The contents of a scientific paper including graphs and pictures can be copied from the publisher’s computer to a local machine in a matter of seconds. The available high speeds allows one to “page” through a reference book with relative ease, even though the electronic copy of that reference may be located in another state. Those same speeds not only facilitate textual communication but also now permit the use of the internet for voice and even live video interactions. Much of the information we need and use on the Internet is available at our fingertips in a matter of fractions of a second.
· Multimedia – The advent of digital technology provides a wider variety of modes for information sharing. Anything that can appear on a printed page can now be digitized and transmitted over the Internet. All of the visual and aural modes such as text in any of thousands of fonts and orientations, high resolution pictures and either black and white or color, sounds, animated graphics and recorded video are now available. Rudimentary tactile information in being transmitted in the form of force (haptic) feedback. The only remaining sense yet to be addressed is the olfactory. By combining these modes into multimedia messages the internet can be used to transmit a great variety of experiences from simple email to real-time, total-immersion, minimally invasive surgical procedures.
·
Interactivity
– The internet is capable of providing a set of experiences in which the
user is encouraged or required to be an active, rather than a passive
participant. This is the essence of the
World Wide Web in which the person viewing a web page makes choices about what
they would like to see or do next by clicking on links within the page. Based upon the choice they are presented with
new information. This type of
interaction forms the basis for many of the web-based instructional programs
because it provides the means of implementing automated feedback to the
participant. Using this technology we
can construct instructional sequences that give constructive feedback depending
on the choice that the user makes and can guide them to materials to help them
learn from and correct their mistakes.
It allows and facilitates implementing the principles of active learning
into web-based instruction. It also
permits the use of new modes of testing where the next question asked depends
on the last answer given by the student.
Institutions of higher learning and professional schools
have taken advantage of the benefits of these information technologies to
create technology enhance learning or TEL.
The
Technology-enhanced learning (TEL) encompasses the broad range of experiences and environments in which technology is used to enhance teaching and learning. Technologies are relentlessly and seamlessly merging, and the lines separating the traditional classroom, the technology-enhanced classroom, and distance learning are disappearing rapidly. TEL initiatives use technology-based resources--video, audio, images, simulations, and library tools--to enrich the learning environment and to extend it from the classroom to the residence hall, the home, the workplace, and the mall.
An Overview of
Technology Enhanced Learning in Medical Education
There are many different types of TEL applications that are
designed for various educational purposes.
In the following sections with we will enumerate the various categories
and relate them to medical education.
Classroom aids (e.g. audiovisual equipment)
At the most basic level, TEL includes the traditional audiovisual
equipment found in medical school classrooms, including projectors (overhead,
slide, and LCD), video recorders connected to televisions or LCD projectors.
Certain classrooms are equipped with graphics tablets that allow the instructor
to “write on” or annotate presentation slides.
In some U of M Schools classrooms are equipment with personal
computers. Other classroom learning aids
available include infrared voting devices and connections for students and
faculty to the Internet (typically wireless).
Some other medical schools have adopted handheld computers as tools to
achieve wireless connections between a lecturer and students.
Instructional Tools (PC, Web, CD, Handheld)
To supplement and sometimes replace verbal presentations, a
variety of TEL tools are widely used.
These include audiovisual instructional aids presented in classroom
settings (e.g. PowerPoint slides), Web-based instruction, multi-media CDs, and
software for handheld computers.
Web-based tools are sometimes formatted inside instructional software
such as WebCT (or
Examples of significant use of TEL instructional aids
include:
Job Aids /
Reference Tools (e.g. Web sites, ebooks)
Tools to assist professionals in consistent or enhanced
performance of specific tasks are sometimes called job aids. They can reduce training time and the need
for memorization. They have been shown to reduce errors due to forgetfulness or
distraction. The most recognizable
example of a job aid is a pilot’s pre-flight check list. This type of
just-in-time TEL in health care is commonly in the format of Web sites
or handheld computer software and is sometimes integrated with electronic
medical records. Health care examples
include:
The federal government and virtually every disease and
specialty-specific organization maintains Web sites with clinical information
for clinicians. The Biomedical Library
supports a widely-used Web-based decision-support/reference tool called
Up-To-Date (also available for Windows Mobile handheld computers). There are a large number of free or modestly
priced medical reference books, documents or calculators are available for
handheld computers. These include
popular print books such as Washington Manual and comprehensive
specialty-specific Palm OS-only tools such as Renal-to-Go (created by a U of M
nephrologists). The State of
Simulations
Simulations and simulators allow students to practice
clinical skills without endangering real patients through . The
Databases
Another common form of just-in-time health care TEL is
electronic databases, searchable on Web sites or handheld computers. The
Communication Tools
Electronic interaction between students and teachers and
from students to each other can be an important form of TEL. Communication can be synchronous (parties on
at the same time) or asynchronous, one way (e.g. group voicemail) two-way, or
multi-party. Methods include email,
teleconferencing (voice or video), and Web-based instructional tools such as
bulletin boards and on-line discussion groups that are provided at the
University by WebCT. Transfer of
content or files from teacher to learner or from one learner to another can
occur via direct connections (voice mail), local area computer networks, the
Internet via WebCT or custom websites, more often now using wireless tools such
as WiFi, Bluetooth, or infrared.
Beyond email, the U of M Medical School’s primary
communication tool, the RPAP program and other groups uses teleconferencing
routinely.
Learner Documentation Tools
An increasingly recognized educational method is asking
students to reflect upon and document their learning experiences. This can be in prose format or as a log of
encounters. As healthcare related TEL,
this takes the form e-portfolios and logs of patients seen or procedures
completed. The University has invested
in and supports a life-long e-portfolio system, but its format has not been
customized for medical student or resident use. The one current example in
undergraduate medical education is the use of a Web-based patient log is used
in the Primary Care Clerkship.
Assessment/Evaluation Tools
Evaluation of student or teacher performance is often
technologically enhanced to improve efficiency of data entry, communication,
and analysis. Even scannable paper
evaluation tools used in Objective Structured Clinical Examinations represent a
form of TEL. Another form of TEL
assessment is the video-enabled examination room, which allows live or taped
review of real or standardized clinical encounters. The
The
Use of TEL Across the
Medical Learner Continuum
Pre-clinical Undegraduate
In the first two years of medical school, TEL is focused on
classroom aids and instructional aids.
The final exam in Physician and Patient at the end of Year 2 uses the
video-enable exam rooms for an OSCE.
Email is the standard communication tool.
Clinical Undergraduate
During Year 3 and 4 of medical school, use of TEL by faculty
is limited to selected clerkships that have course directors interested in
TEL. Almost all students carry handheld
computers (purchased personally) with a variety of ebooks or other reference
materials installed. MEDLINE is used
occasionally, but textbooks and Web sites are more common sources of learning
about diseases. As noted above,
teleconferencing assists learning in RPAP.
Communication with preceptors is almost entirely verbal
Graduate Medical Education
During residency, TEL is focused on handheld computer
applications, with the largest residency programs purchasing handhelds for
their residents (IM and FP). E-books and
other reference tools are indispensable for most residents. MEDLINE is used frequently by residents as
their knowledge needs are more urgent and surpass textbook offerings. Classroom education has little TEL use, as it
is most often small group (e.g. on rounds).
A number of specialty or sub-specialty specific CDs are available for
self-learning. Communication with
preceptors is almost entirely verbal but E*Value is used for evaluations of resident
performance.
Continuing Medical Education
Formal continuing medical education uses classroom aids for
on-site conferences. Web-based CME is
widely available, although the U of M has not pursued this approach to any
significant degree. Web-based, video,
and phone based teleconferences are common for 1-hour CME sessions. There have been some efforts to expand formal
CME to handheld computers (in 5-10 minute increments as part of drug database
searches).
Practicing Physicians
Few practicing physicians outside academics use MEDLINE more than rarely, but reference CDs such as Up-to-Date are popular for office-based use. Board re-certification programs often include CD-based instructional aids. Physician decision support within EMRs remains in its infancy and is not yet significant within the UMP EMR system. About ½ of practicing physicians carry handheld computers (declining with age), with drug databases the most popular medical database software.
Current Technology
Infrastructure
The
What does the research literature tell us about the impact of TEL?
Accompanying this White Paper are several references that review findings with respect to the use of TEL in medical education. They attempt to address a number of questions including:
The following summarizes the conclusions of those articles.
· TEL works. It is possible to create technology enhanced learning applications like those described above that are capable of achieving their stated objectives. They work reliably and students can use them for learning, evaluation and communication. Students can and do make use of and learn from TEL materials and strategies.
· Computer-based independent learning is at least equivalent to standard teaching methods in producing student learning. Repeated well-designed studies have demonstrated this finding. Some studies have found that TEL based independent learning methods produce greater learning than traditional teaching methods.
· Learning can be faster with TEL materials. Of the several studies that have examined the issue of time to achievement in TEL-based independent learning, most have demonstrated learning may take longer using traditional teaching methods. This likely due to the fact that students in traditional teaching are controlled by the instructor’s pace, but in TEL-based independent learning they can proceed at their own pace. If this pace is quicker than that set by the instructor, faster learning is likely to result.
· Given a choice, students generally prefer face to face teaching. While students can use and learn from TEL based independent learning, they report a continuing preference for a live teacher. This may well be due as much to the fact that their entire educational experience is within the conventional system and they have not yet developed the skills to learn independently in a TEL environment. There is also the very real advantage that the learning environment in which teaching is done by a live instructor can be more flexible and responsive to students than an TEL environment.
· TEL methods are likely to be more work for the instructors than the conventional lecture. Development of TEL materials is often reported to require more time and resources than the lectures even with the advent of PowerPoint presentations. In many ways the development of TEL materials is equivalent to writing a textbook – except that the textbook is in an electronic format and is in a more complex format than the typical printed textbook. In addition those TEL strategies that involve electronic communications with students either through email, discussion boards or chat rooms may require more instructor time than traditional office hours.
· On line materials are relatively expensive to develop. Creation of TEL-based learning materials is often beyond the expertise of the typical teacher and usually requires the time and skills of educational technology specialists. These same specialists are also often needed to maintain and update the materials. In addition special purpose hardware is sometimes requires such as when creating video clips or conducting videoconferences. All these are costs over and above the normal costs of instruction.
While the technology does provide these new opportunities we must recognize that we are at the very beginning of the development of educational technology in Medical Education. There is a well know cycle of technology development in which the first applications of the technology replicate existing processes and methods in a new form. Granted that there may be significant improvements in some ways, but the underlying processes and approaches have not changed. Only after a new technology is explored for a while are truly innovative and unexpected uses made of it. Many of the uses of technology in Medical Education today exemplify this first stage of the cycle. Class websites provide links to electronic versions of printed handouts, independent study modules are often lecture recordings with accompanying PowerPoint slides. On line tests are reproductions of paper tests in an electronic environment. PDAs provide quick access to pocket diaries. Electronic search engines like PubMed provide the same means of searching the literature as was available through the Index Medicus. While each of these examples does reproduce an existing educational method in a new form they, in many cases also provide significant improvements upon that form. We need to accept the fact that the process of innovation in Medical Education, like any other area of endeavor must proceed through this development cycle.
The Challenge
The challenge we face in examining the uses of technology in Medical Education is to make the best judgments how to take advantage of its positive characteristics to improve the educational process and achieve the education mission and goals of the School. We do not use technology for its own sake, but rather as a method of enabling more effective and efficient achievement of that mission. The Dean has identified three areas of education priorities and has asked us to address each by considering if technology enhanced learning could facilitate them and if so which ones and at what price.
In this paper we have reviewed the promise of the technologies that are used in TEL, described the different categories of TEL use in medical education and summarized the findings of the educational research literature with respect to technology enhanced learning. Our task is to make use of this information to address the issues we face and to provide the best possible answers to the following questions:
1. How can we best use these technologies to ensure comparability of learning experiences between campuses and among program sites as required by LCME, ACGME and ACCME?
2. What is the role of these technologies in promoting scheduling flexibility and independent learning in our educational programs?
3. How can these technologies be used to facilitate rigorous, reflective, outcomes-based evaluations of student knowledge and skills.
TEL Best Practices at the University of
|
Best Practice |
Description |
Contact |
|
Anatomy |
The Program in Human Anatomy Education web site is a
source of information on Anatomy courses at the |
Ken Roberts |
|
Physician and Society |
Physician and Society is a set of courses in the first and second years of the curriculum that focus on a variety of social science, epidemiologic, cultural, ethical and health system issues. The course is supported by a website that maintains a number of resources for the students and is available at www.meded.umn.edu. The course uses an online, anonymous survey to collect health information and medical care preferences from the students and constructs a simulated health plan around those references. The students assume the role of plan administrators and throughout the Year 1 course consider a variety of plan-related issue and make decisions by an online voting process that feeds back into class presentations. The Minnesota Virtual Clinic is used to present patients that raise issues about cultural and ethical considerations. In Year 2 the course has converted a number of classes to the asynchronous presentation approach. During certain weeks, the students are required to sign on to WebCT, view narrated PowerPoint presentations and answer questions regarding those presentations. |
James Pacala Karyn Baum |
|
Physician and Patient |
This second year medical school course is designed to provide students with their first hands-on experience performing histories and physical examinations on patients in a variety of real-life clinical settings. Technology is used to both teach and evaluate students. One of the 18 full-day sessions of this course includes a structured home-visit experience to a senior to teach students house call etiquette and comprehensive assessment of the older patient; the experience is called Seniors as Teachers. It uses multi-media Web site (www.geriatrics.umn.edu) that contains detailed written instructions on why and how to perform a house call, photos of seniors' home environments, and streaming video of Dr. Ratner interacting with seniors. This Web site effectively substitutes for one-on-one mentoring in the home setting, which would be logistically impossible with over 160 medical students per year. In the past four years, over 1800 visits to this site have been made by students and faculty from the U of M and elsewhere. At the end of the Physician and Patient series of courses, students are assessed through a set of simulated patient encounters that are video recorded for faculty review and, if necessary, use in remediation.
|
Sharon Allen Ed Ratner |
|
Histology Time |
Histology Time on CD is an interactive multimedia computer
program that instructs the student in the fundamentals of histology and
provides a mechanism for student self-testing of those fundamentals in a
non-punitive way. It incorporates a
large number of histology images (~5,000 images) from the videodisc
Histology: A Photographic Atlas (Stephen Downing, author). Histology Time on CD is divided into 19
chapters that cover the basic subject areas covered in a typical histology
course. Each chapter has four parts:
(1) a MicroLab session where the student is given basic information about the
specific tissue or organ system being covered; (2) a Quiz Time session where
the students are quizzed on their understanding of the visual material; (3)
an MC Exam session which tests the students on their understanding of
material typically covered in the lecture component of a histology course;
and (4) a K Exam session which also tests students on their understanding of
material typically covered in the lecture component of a histology
course. Significant benefits of using
this program include the following: (1) eliminates the need to use
microscopes in our curriculum; (2) students learn the material in a fraction
of the time that was formerly required; (3) the amount of faculty time that
needs to be devoted to laboratory exercises has been greatly reduced; (4)
permits rapid and extensive review of histological principles and
histological images; (5) makes tutoring of students on the visual components
of histology very easy; (6) makes the laboratory component of histology very
portable (students can have the entire program on a single CD-ROM and can
study at home, on an airplane, or wherever they have access to a
computer). There are PC- and
Macintosh- compatible versions available and the program is currently in wide
use throughout the |
Stephen Downing |
|
Neurotime |
NeuroTime® is an interactive computer-based learning tool developed to facilitate the learning of neuroanatomical structures, their relationships and terminology using high quality images of intact and dissected gross specimens plus a series of whole brain sections in the coronal, horizontal and sagittal planes. Corresponding magnetic resonance images (MRIs) enable the student to apply this structural knowledge to the interpretation of magnetic resonance scans. In Identification Mode the student selects the name of a structure and a corresponding transparent, colored overlay appears over the structure. In Quiz Mode the student can assess their level of knowledge. Since this tool is delivered on CD-ROM for Macintosh or Windows systems, students are able to study all gross specimens, brain sections and MRIs at any time and place they have access to a computer. Students find this to be a very efficient way to study neuroanatomy since 1) they do not waste time looking for specimens in the lab, searching for the names of structures or waiting for an instructor's feedback 2) they can navigate to the areas they wish to study and receive immediate feedback and 3) they can study when they are prepared to learn. NeuroTime® can be used in conjunction with gross specimens or independently where specimens are unavailable. Since it can replace wet specimens, its use reduces exposure of faculty and students to formalin, saves faculty time and eliminates the cost of maintaining a wet lab facility. NeuroTime® can be adapted for use in any curriculum that requires a knowledge of neuroanatomical structures. |
Donna Forbes |
|
Pathology |
Currently the Pathology courses website offers students 24 hour access to course information including: lecture handouts and PowerPoint presentations, laboratory preview images and laboratory answers, laboratory review images and handouts, grades, and announcements. Each period is self-contained and password protected for safe and efficient access to materials. All presentations are in a downloadable/printable format. Currently we are working on a database system to allow faster access and to have a more interactive site. The main goal of this effort will be a comprehensive and fully searchable materials and image database to allow students to more easily reference any pathologies that they were taught during the Years 1 and 2 courses. |
Dan Dykoski |
|
Medicine and Pediatric Clerkships |
The Medicine Clerkship has the website www.imclerkship.umn.edu which has general information regarding the course. It has links to each of the clerkship sites (Abbott, HCMC, VAMC, Regions, FUMC) with site specific information that students can use to prepare for the rotation. The site also has the coursebook as well as a number of the lectures and handouts available for students to download for review or to look at if they missed a lecture. There is a clerkship CD ROM with clinical cases that is distributed on the first day. The CD has all of the papers that the students use to prepare for the lectures and all of the course handouts and information they can use to improve their write-ups and presentations. It also contains all of the materials they use for their portfolio. The students also get a Physical Diagnosis Teaching CD with video clips, heart sounds, lung sounds and papers that are meant to supplement the physical diagnosis rounds the students have.
In the Pediatric Clerkship students have access to the website www.peds.umn.edu which has site specific information similar to the medicine clerkship. Within the website is the coursebook, practice questions, a link to interactive practice cases (www.clippcases.org) and a link to an on-line site featuring videos used to teach the pediatric physical exam. We also encourage students to use their PDAs and give them a link to the PDA version of Pediatric One Minute Clinical Consult. |
James Nixon Brad Benson |
|
Primary Care Clerkship |
The primary care clerkship provides clinical experiences
for medical students at a wide variety of sites scattered throughout the
Minneapolis/Saint Paul and |
David Power |
|
Neurology Clerkship |
The neurology clerkship website provides a number of
resources for the student. The
neurology tutorial syllabus is available and allows medical students to study
the syllabus anywhere, anytime, provided they can access the web. There are
also links to supplementary information at appropriate locations throughout
the syllabus. We have attempted to provide some vertical integration of
curricula by linking to relevant course materials from the year 1 medical
neuroscience and year 2 pathophysiology courses, as well as American Academy
of Neurology practice guidelines, supplementary chapters on stroke and
neuromuscular disease which Dr. Walk has written in order to provide more in
depth clinical information, useful external websites, and a neurologic
examination streaming video. Dr Tuite has added supplementary videos and
powerpoint presentations. We hope to add more information over time, and have
charged a radiology faculty member with adding a neuroradiology
tutorial. The clerkship also has used
webCT combined with a modified version of the Minnesota Virtual Clinic for a
virtual patient designed to teach fundamental principles in medical
professionalism and ethics. The site
also has an internal NBME shelf-style examination for the students to take as
a practice test on webCT. One of the
clerkship sites is in |
David Walk |
|
HIPAA training offered by the AHC |
The |
Janet Shanedling (AHC) |
|
|
The |
Richard Hoffman |
|
Lectures on Line |
Lectures on Line is a student initiated and |
Stuart Speedie |
|
Curriculum Database |
The curriculum database is a collection of information representing the first four years of the medical school’s curriculum. In the first two years it is organized around class schedules and in the last two years by clerkship. The goal of the database is to capture and represent the information, knowledge and skills covered in every educational experience that occurs during those years. For each Year 1 and 2 lecture a topic list is obtained and used to index that lecture. In addition, if a PowerPoint presentation was used or supplemental materials such as handouts were provided in electronic form they are also included as well as links to Lectures on Line. Information in the database is retrievable in two ways. A master calendar provides links to all sessions of all courses in the first two years. There is also a search mechanism similar to Google™ that allows free text searching on any term. These searches return all of the lectures and clerkships that include the search term. Thus it presents a powerful tool for faculty and students to locate where and when in the curriculum a particular topic is covered. |
Stuart Speedie |
|
E*Value |
The E*Value system is a web-based system for evaluating students during their clerkships and for students to provide feedback on their experiences in those clerkships. If presents a series of questions on a web page that were designed by evaluation experts in the Medical School and to which the evaluator responds to by selecting the appropriate option or typing in a comment. Central to the system is a master schedule that details when each student will complete each clerkship. When the end of a clerkship approaches, the system automatically emails the clerkship director or site director with a reminder to complete the evaluation for the current students. It tracks completion of the evaluations and will send reminders when needed. The system also emails the students to remind them to complete their evaluations of the clerkships. E*Value provides a series of summary reports of these evaluation activities that are used by the clerkship directors to assign grades and to make changes in the clerkships based on student evaluations. E*Value plays a similar role for graduate medical education and is used by a number of residency programs for the same purpose. |
Theodore Thompson |
|
Classroom Response System |
Classroom response systems are typically used during a
lecture to solicit individual responses during class. After covering a topic, the lecturer
presents a multiple choice question and ask the students to select which
alternative they think is correct. These systems uses individual response
units much like a TV remote with a series of buttons. Receivers in the room are capable of
detecting when a button is pressed on a unit and each unit has a unique
identifier so that responses are not counted multiple times. These receivers are connected to a
computer that automatically collects the responses and aggregates them into a
histogram or some other figure. Based
on the responses the lecturer can adjust his or her presentation. The |
Richard Hoffman |
|
Laptop Purchase Program |
Working with campus information technology partners, the |
Richard Hoffman |
|
SimMan, CathSim |
Since Fall 2003, SimMan has been used to train medical,
nursing, and pharmacy students in everything from basic physical exam skills
to the elements of successful team performance in acute care scenarios. SimMan has also been used to train |
Jane Miller |
|
GME Online Core Curriculum |
The GME online core curriculum provides an opportunity for residents who are not able to attend the live presentations of the GME Core Curriculum to review those presentations at a later time. The video and audio of all core curriculum presentations are recorded and converted to streaming video files. A WebCT course was created for the core curriculum and provided links to each presentation. When a student selects a particular presentation, they must identify themselves and indicate their residency program. This is followed by a short, pre-presentation confidence assessment concerning the topic. The student then goes to a page that has a short biography of the presenter along with links to the streaming video presentation and the PowerPoint slides which the student can view at the same time in different windows on the screen. When the viewing is completed, the system records the amount of time spent viewing the video and asks a series of evaluation questions and another confidence assessment. By completing this process the resident can provide evidence that they have completed the necessary core curriculum sessions. |
Lisa Wichman |
Technology Enhanced Learning Methods
The following table
lists a variety of TEL methodology for instruction and evaluation. They are presented as a list of alternative
approaches that can be used in medical education. The table provides a brief description of
each methodology and lists some of the tools that are available to implement
that methodology.
|
TEL Method |
Description |
Tools |
|
Instructional Methods |
||
|
Recorded presentations |
Recorded presentations often combine PowerPoint slides and audio narration that is captured digitally and made available to students at their convenience. They provide the student with the ability to study the material at a time optimal for them and to review the exact content numerous times. Students and rewind and replay as desired. They are typically created either by recording a live lecture or by the instructor narrating the presentation at the computer. |
Breeze Presenter Narrated PowerPoint Lectures on Line |
|
Live distributed presentations |
Live distributed presentations are presentations that are distributed to one or more additional locations using videoconferencing systems such as Polycom or using networks and servers such as Breeze Live. These sessions can be interactive with the ability of students to ask questions and respond to the leader’s questions. |
Videoconferencing Breeze Live MS Instant Messaging Polycom PVX PC |
|
Live Group discussions |
Live group discussions can use the same technology as live distributed presentations but the instructional goal is to teach by discussion rather than lecture. They can also be entirely web-based using online chat technologies like instant messaging. They all facilitate discussions among geographically dispersed participants when all are available at the same time. |
WebCT Vista Chat MS/AOL/Yahoo IM Breeze Live Videoconferencing |
|
Asynchronous Group discussions |
The goal of asynchronous group discussions is to promote discussions among groups of geographically distributed participants when those persons cannot or do not wish to be available during the same time period. This method allows extended interactions for the purpose of exchanging information or reacting to others ideas. |
WebCT discussion groups Blogs myAHC Portal discussions |
|
Online Case Presentations |
Online case presentations are cases delivered to students via web pages that illustrate various clinical scenarios and will often lead the student step by step through those scenarios. They may be a simple as a static web page or may involve multimedia presentations and user interactions in order to teach about clinical skills or other topics. There are a number of tools for creating these case presentations that incorporate templates for case descriptions. |
Web Pages DxR CLIPPs Numerous others |
|
Online readings |
Online readings are a method to link students to the literature available on the Internet. This is typically accomplished by embedding web links into web pages that will take the student to the desired article of particular location in a reference. |
Web pages Full text databases Full text references Bio-Medical Library tools. |
|
Online assignments |
Online assignments are a means to deliver assignments to students and to collect the assignments that are submitted for review and grading. WebCT provides the means to grade these assignments and distribute feedback to individual students. |
WebCT Assignments Active Websites |
|
Online Group Projects |
Online group projects combine online assignments with group discussion methods to assist student to work together on projects when they cannot meet face to face. It is possible to limit the discussion groups to just the participating students and an instructor if desired. |
WebCT Private discussions and assignments myAHC discussion groups |
|
Interactive, directed Learning |
Interactive, directed learning is a method of online teaching where the information to be presented is divided up into small units that can be presented on a typical web page. Often the students will be required to take some action such as answer a question to verify that they understand the presentation before proceeding. Multimedia elements including video and audio clips as well as animated illustrations may be part of such units. The student may proceed through each unit in a sequence determined by the designer or may be allowed the freedom to choose their own path.. This approach is also commonly referred to as a learning module. |
Custom websites Macromedia Director |
|
Computer-based simulations |
A computer-based simulation uses a model of some medical phenomena such as electrolyte balance to teach about a particular topic. The model allows the student to explore the consequences of various changes that can occur or are made to occur as the result of different disease states or therapeutic decisions. It can also be used to create various scenarios for the student to interact with much like the case presentations described above. |
Custom websites Commercial Products. |
|
Physical simulations |
Physical simulations are similar to or even incorporate computer-based simulations but realize the results of the simulation in a physical model that students can touch and feel in order to practice and learn physical clinical skills such as intubation, venipuncture or endoscopic skills. These simulators provide tactile feedback to help students learn their skills. They are usually quite complex interactions of physical and computer components. To be used as a teaching tool, scenarios need to be defined that determine how the model will operate and react to the inputs provided by students. |
SimMan CathSim Many other commercial simulations |
|
Virtual Reality |
Virtual reality is a form of computer-based simulation which attempts to provide a 3D environment in which the student is totally immersed. One example is derived from the Visible Human project that provides the means to “fly through” the GI system to view internal components that would be difficult to demonstrate otherwise. This is a cutting edge technique this is just being developed for educational purposes. |
Visible Human |
|
Self-testing with feedback |
Self testing quizzes are a useful device for students to test their knowledge in a particular area. Asking a question and providing different choices of answers along with explanations of why each answer is either or correct or incorrect. The WebCT quiz tool allows the instructor to make these self-testing quizzes available for students to use at their convenience. |
WebCT quiz tool Custom websites Breeze Presenter |
|
Evaluation |
||
|
Multiple choice testing |
These are questions in which the instructor poses a question or situation in the stem of the question with directions for the student to make some choice or choices. The question may include pictures, illustrations, video and audio clips if desired. A set of alternatives is provided and the student is expected to select one or more in response to the directions. In online testing neither the number of choices or the number of correct answers is not limited to specific number. Answers can be automatically scored and recorded for each student. |
WebCT testing tool |
|
Short answer questions |
In this type of question, the instructor poses a question and sect of directions and the student is required to respond with a one or two word answer. If the instructor supplies a list of correct answers, these questions can be automatically scored and recorded. |
WebCT testing tool |
|
Essay questions |
Essay questions can be used in online testing and the system will record the student’s answers, but they must be manually graded by the instructor or their representatives. The system will record the scores and incorporate them into a final test score if desired. |
WebCT testing tool |
|
Matching |
Matching questions are an efficient means of asking a number of multiple choice questions about a particular topic such as identifying anatomic structures. The WebCT testing tool permits partial and weighted scoring of matches. |
WebCT testing tool |
|
Computer-based simulations |
Computer-based simulations have been described above as teaching tools. They can also be used for evaluation of student knowledge and skill by presenting the student with a scenario to which they are required to respond. The responses are evaluated by an expert or can be automatically scored if acceptable responses are predefined. |
Custom websites Commercial Simulations |
|
Physical simulations |
Physical simulations can be used for evaluation in the same manner as computer-based simulations with the added benefit that performance of physical skills can be observed and evaluated. |
SimMan CathSim Many others |
|
Expert judgments |
Information technology can be used to facilitate the observation and expert evaluation of clinical skills. It does this by providing online reminder lists of what should be observed and evaluated as well as providing a mechanism for recording and reporting the results of those evaluations. |
E*Value CoursEval Custom websites |
|
Performance review |
Information technology can facilitate the review and evaluation of a variety of work products that students may generate to demonstrate their competence in various areas of medicine. This is accomplished by created a repository for individual student’s digitally realized works that they can share with and have evaluated by faculty. These might include patient education materials, educational videos, recorded clinical performance, written documents among but a few examples. Tools such as ePortfolio provide a means to store and retrieve these materials and make them available for evaluation. |
ePortfolio E*Value |
|
Skills and Competency checklists |
Skills and competency checklists are a means of tracking student performance and achievement over time. Information technology can make such lists available online and can provide the means for multiple individuals including students and instructors to record and verify achievement of those skills and competencies. |
E*Value Custom websites |